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Medical Transportation – Ground1

This section contains information on ground medical transportation services and program coverage (California Code of Regulations [CCR], Title 22, Section 51323). For additional help, refer to the Medical Transportation – Ground: Billing Examples section in this manual.

GENERAL INFORMATION

Program CoverageMedi-Cal covers ambulance and other medical transportation only when ordinary public or private conveyance is medically contra-indicated and transportation is required for obtaining needed medical care.

Eligibility RequirementsTo receive reimbursement, a recipient must be eligible for Medi-Cal on the date of service.

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Medical Transportation – Ground1

EMERGENCY GROUND MEDICAL TRANSPORTATION

Transportation toMedi-Cal covers emergency ground medical transportation to the

Nearest Hospitalnearest hospital capable of meeting a recipient’s needs. When the geographically nearest facility cannot meet the needs of a recipient, transportation to the closest facility that can provide the necessary medical care is appropriate under Medi-Cal. Coverage will be jeopardized if a recipient is not transported to the nearest acute hospital capable of meeting a recipient’s emergency medical needs (contract or non-contract).

Note:In non-emergency situations, physicians and hospitals must adhere to hospital contract regulations and admit recipients to the nearest contract hospital.

Transportation to aRecipients transported to a non-contract hospital must be taken to the

Second Facilitynearest contract hospital as soon as they are stable. Recipients are

considered stable for transport when they are able to sustain transport in an ambulance staffed by an Emergency Medical Technician I
(EMT I) with no expected increase in morbidity or mortality as a result of the transportation. In addition, if a recipient is an infant, the ambulance must have necessary modular equipment.

When the nearest facility serves as the closest source of emergency care and a recipient is promptly transferred to a more appropriate care facility, transportation from the first to the second facility is considered a continuation of the initial emergency trip. However, the transfer is not considered a continuation of the initial emergency trip if the provider vehicle leaves the facility to return to its place of business or accepts another call.

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Emergency StatementAll emergency medical transportation requires a statement in the Reserved For Local Use field (Box 19) of the claim, or on an attachment, supporting that an emergency existed. The statement may be made by the provider of transportation and must include:

  • The name of the person or agency that requested the service
  • The nature of the emergency
  • The name of the hospital to which a recipient was transported
  • Clinical information on a recipient’s condition
  • The reason the services were considered to be immediately

necessary (medical necessity)

  • The name of the physician accepting responsibility for the recipient

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NON-EMERGENCY GROUND MEDICAL TRANSPORTATION

Non-Emergency CoverageNon-emergency medical transportation is covered only when a

recipient’s medical and physical condition does not allow that recipient to travel by bus, passenger car, taxicab, or another form of public or private conveyance. Transport is not covered if the care to be obtained is not a Medi-Cal benefit

Non-emergency medical transportation necessary to obtain

medical services is covered subject to the written prescription of a physician, dentist or podiatrist.

Prior AuthorizationA Treatment Authorization Request (TAR) is required for
non-emergency transportation. A legible prescription (or order sheet signed by the physician for institutional recipients) must accompany the TAR.

All TARs for non-emergency medical transportation must be

submitted to either the Sacramento or San Diego Medi-Cal Field

Office. See the TAR Field Office Addresses section in this manual

for regional coverage by the appropriate Medi-Cal field office.

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Prescription RequirementsThe prescription (or order sheet signed by the physician for institutional recipients) that is submitted with a TAR must include the following:

  • Purpose of the trip
  • Frequency of necessary medical visits/trips or the inclusive dates of the requested medical transportation
  • Medical or physical condition that makes normal public or private transportation inadvisable

Note:When transportation is requested on an ongoing basis, the chronic nature of a recipient’s medical or physical condition must be indicated and a treatment plan from the physician or therapist must be included. A diagnosis alone, such as “multiple sclerosis” or “stroke,” will not satisfy this requirement.

The Medi-Cal field office consultant needs the above information to determine the medical necessity of a specialized medical transport vehicle and the purpose of the trip. Incomplete information will delay approval.

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Transport From AcuteA TAR is not required for non-emergency transportation from an acute

Care Hospital to Longcare hospital to a long term care facility. This is an exception to the

Term Care Facilitypriorauthorization requirement. This policy applies to transportation for

recipients who received acute care as hospital inpatients who are being transferred to a Nursing Facility (NF) Level A or B.

This service must be billed with one of the appropriate non-emergency transportation codes (HCPCS codes X0400 – X0416). Refer tothe Medical Transportation – Ground: Billing Codes and Reimbursement Rates section in this manual for code descriptions and rates. Services billed with other non-emergency transportation codes require prior authorization.

Note:Medi-Cal does not cover waiting time or night calls for transport from an acute care facility to NF-A care.

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Transportation to AdultNon-emergency transportation between a recipient’s home and an

Day Health CareAdult Day Health Care (ADHC) center is included in the per diem

(ADHC) Centersreimbursement rate paid to an ADHC center and is not separately reimbursable. Therefore, a TAR submitted to the field office for
non-emergency transportation between a recipient’s home and an ADHC center will be denied.

A TAR is required for non-emergency transportation services provided to and from medical, dental or podiatry appointments only. (An ADHC center provides health, therapeutic and social services in a community-based day care program for recipients 18 years of age or older.)

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ReimbursementSeparate reimbursement is not made for services or items included in the base rate, such as:

  • Backboards
  • Flat/scoop stretchers
  • Long boards
  • Disposable oxygen masks and tubing
  • Disposable I.V. tubing
  • Childbirth assistance
  • Restraint of recipient
  • Suction/suction equipment
  • Resuscitation
  • Ventilator/Respirator/Intermittent Positive Pressure Breathing

(IPPB)

  • A crew of two persons
  • Pick-up off paved road
  • Pick-up of overweight or difficult-to-reach recipients
  • Linens and blankets

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Types of Ground MedicalNon-emergency medical transportation is provided by three types of

Transportationvehicles: ambulance, litter van and wheelchair van.

Ambulance:Ambulances are generally used for emergencies, but may provide

Qualified Recipientsnon-emergency transport for certain types of recipients.

Non-emergency transport by ambulance can include:

  • Transfers between facilities for recipients who require continuous intravenous medication, medical monitoring or observation
  • Transfers from an acute care facility to another acute care facility
  • Transport for recipients who have recently been placed on oxygen (not chronic emphysema recipients who carry their own oxygen for continuous use)
  • Transport for recipients with chronic conditions who require oxygen if monitoring is required

Ambulance:Non-emergency transport by ambulance does not include:

Non-Qualified Recipients

  • Individuals with chronic conditions who require oxygen, but do not require monitoring. Such individuals should be transported in a litter van or wheelchair van when all of the following criteria are met:

–Cannot use public or private means of transportation

–Clinically stable

–Can transport upright in a litter van or wheelchair van

–Able to self-monitor oxygen delivery system

–No other excluding conditions

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Litter VanTransport by litter van is appropriate when a recipient’s medical and physical condition:

  • Require that the recipient be transported in a prone or supine position because the recipient is not able to sit for the period of time needed for transport.
  • Require specialized equipment and/or more space than is normally available in passenger cars, taxicabs or other forms of public transportation.
  • Do not require the specialized services, equipment and personnel of an ambulance because the recipient is in a stable condition and does not need constant observation.

Examples of recipients who qualify for litter van transport include:

  • Recipients in a spica cast
  • Bed bound recipients
  • Post-operative, stable recipients who cannot tolerate sitting upright for the time required for transport from pick-up point to destination
  • Individuals with chronic conditions who require oxygen, but do not require monitoring

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Wheelchair VanTransport by wheelchair van is appropriate when a recipient’s medical and physical condition:

  • Render the recipient unable to sit in a private vehicle, taxicab, or other form of public transportation for the time needed for transport
  • Require that the recipient be transported in a wheelchair
  • Render the recipient unable to transfer unassisted from a residence to a public or private conveyance because of a disabling physical or mental limitation
  • Do not require the specialized services, equipment and personnel of an ambulance because the recipient is in a stable condition and does not need constant observation

Examples of recipients who qualify for wheelchair van transport include:

  • Recipients who suffer from severe mental confusion
  • Recipients with paraplegia
  • Dialysis recipients
  • Individuals with chronic conditions who require oxygen, but do not require monitoring

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BILLING INFORMATION

Trips With MultipleWhen more than one recipient is transported to the same destination

Recipientsin the same vehicle from a common loading point, the provider must indicate on each claim submitted the names and Medi-Cal ID numbers (if applicable) of the other recipients transported.

“Response to call” codes for billing transportation of more than one recipient are listed in the Medical Transportation – Ground: Billing Codes and Reimbursement Rates section in this manual. For each trip with multiple recipients, the medical transportation provider must bill Medi-Cal with the appropriate HCPCS code for each recipient and only once for the following:

Ambulance

/

Litter Van and Wheelchair Van

HCPCS
CodeDescription / HCPCS
CodeDescription
X0006Emergency Run / X0216Mileage
X0010Waiting Time / X0218Night Call
X0034Mileage

When billing for a trip with multiple recipients, the above items must be billed only on the claim submitted for the first recipient transported. For recipients other than the first recipient, the provider may bill only “response to call” codes as appropriate and services other than those listed under “Trips With Multiple Recipients” (for example, HCPCS code X0036 for oxygen in an ambulance or HCPCS code X0220 for oxygen in a wheelchair van).

Note:The above policy does not apply to recipients picked up at different points of origin or delivered to different destinations.

When multiple patients are picked up from the same location and transported to the same location, a TAR is required for each patient. The names of all transported patients and the TAR Control Numbers of all the submitted TARs must be documented in the Medical Justification area of each TAR. If the area is not sufficient for the required information, enter “see attached” and include the information on an attached 8 ½ x 11-inch sheet of paper.

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TARs for Multiple RecipientsA single TAR may be approved for multiple patient trips. If the TAR is approved for three or more patients, but fewer patients are transported than authorized on the TAR, a new TAR is not required if the trip still meets the multiple patient trip definition (more than one patient transported from a common point). However, if a multiple patient trip is authorized and only one patient is transported, a new TAR is required.

Multiple Trips forIf multiple trips for the same recipient are provided on the same date

Same Recipientof service, enter the time of day and the points of destination in the

Reserved for Local Use field (Box 19) of the CMS-1500 claim. Without this information, second and subsequent trips may be denied as duplicate services.

Round-TripsWhen billing round-trips, enter the appropriate “response to call” procedure code on one billing line, showing a “2” in the Days or Units field (Box 24G) and one charge for this portion of the service.

Transportation From andTo bill for transporting a recipient who remains an inpatient from an

Back to a Hospital: Placeinpatient hospital, providers must enter Place of Service code “21”

of Service Code “21”(inpatient hospital) in the Place of Service field (Box 24B). Also, they must enter the provider address and NPI of the inpatient hospital of pick-up in the Service Facility Location Information field (Boxes 32 and 32A).

If the trips from a hospital to a doctor’s office and back to that hospital are billed as two separate trips, both must be billed with Place of Service code “21.”

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MileageTo bill for mileage, enter HCPCS code X0034 or X0216, as appropriate, and show the total miles from point of recipient pick-up to destination (and return mileage for round-trip billing) in the Days or Units field (Box 24G). The complete origination and destination addresses, including city and ZIP code, must be indicated in the Reserved for Local Use field (Box 19) of the claim.

If an origination or destination address is not available, the following types of origination and/or destination sites are reimbursable when accompanied with documentation that the emergency occurred in an area where no specific address is available, with a description of the location, either in the Reserved for Local Use field (Box 19) or on an attachment:

  • Interstate, highway or freeway
  • Indian lands and reservations
  • Bodies of water and their shorelines
  • Campgrounds
  • State and national parks and recreation areas
  • Mountains
  • Deserts
  • Farms and ranch land

Night CallsWhen billing for ambulance transport services between the hours of
7 p.m. and 7 a.m., use code X0030 (ambulance service, Basic Life Support [BLS] base rate, emergency transport, one way) with modifier UJ (services provided at night). Indicate the time of the service in the Reserved for Local Use field (Box 19).

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Dry RunMedical ground transportation providers may be reimbursed for

responding to a call, even if the recipient was not transported (dry run). Providers must document “dry run” in the Reserved For Local Use field (Box 19) of the claim, or as an attachment, and explain why the recipient was not transported.

Emergency CallUse HCPCS code X0030 (ambulance service, Basic Life Support [BLS] base rate, emergency transport, one way [includes allowance for emergency run]) when billing for response to an “emergency” (911) call. This is reimbursement for a call with the purpose of transport, even though the person was not available to be transported, and is not reimbursement for a non-transporting county EMT team. (Mileage is not reimbursed.)

Non-Emergency TripUse HCPCS code X0200 (response to call; one patient) when billing for response to a “non-emergency” trip, if there is an approved Treatment Authorization Request (TAR). This is not reimbursement for a non-transporting county EMT team. (Mileage is not reimbursed.)

Refer tothe Medical Transportation – Ground: Billing Codes and Reimbursement Rates section in this manual for rates.

Waiting TimeProviders may bill for medical ground transportation waiting time in excess of the first 15 minutes using either HCPCS code X0010 (ground ambulance waiting time over 15 minutes; each 15 minutes) for ground ambulance services, or HCPCS code X0214 (waiting time over 15 minutes; each 15 minutes) for wheelchair van and litter van transportation services. Each 15-minute increment is billed as a quantity of one (1). A maximum of 90 minutes (six units) of waiting time in excess of 15 minutes may be reimbursed. Waiting time in excess of 1½ hours will not be reimbursed. In addition to justifying the wait, providers must also document the clock time when the wait began and ended in the Reserved For Local Use field (Box 19) of the claim or on an attachment.

An exception to the 90-minute waiting time is made for ground ambulance service (X0010) in cases where the recipient is a neonate. Providers may be reimbursed up to eight hours (32 units) in excess of the first 15 minutes when documentation indicates that the waiting time was required to stabilize a neonate before transport.

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